Home Health Care Providers Must Pay Attention to Documentation or Risk Penalties
December 10, 2012 11:08 am

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By Jennifer Shimek

Home health care is a critical service for our nation’s aging patients. Providers bring skilled and unskilled care to the patient’s home, including everything from nursing care to assisting with daily tasks.

The Department of Health and Human Services Office of Inspector General (OIG) identifies these home health services as a key area vulnerable for fraud waste and abuse.  In 2010 alone, the OIG estimated that Medicare paid home health agencies (HHA) over $19.5 billion for submitted claims.  As a result, home health services, again, has been included as a focus area for the OIG in the Office of Inspector General Work Plan Fiscal Year 2013.

Audits, penalties, settlement agreements and corporate integrity agreements (CIAs) are common in the home health industry.  Consequently, home health providers need to be aware of the issues and compliant with regulatory requirements. The Centers for Medicare & Medicaid Services (CMS) continues to increase its audits of the industry, and home health providers should be adequately prepared for an audit when it is their turn.  For example, in 2011, a home health provider agreed to pay $150 million to resolve criminal and civil investigations pertaining to fraudulent billing activities with the government.  In 2012, the largest home health fraud case in U.S. history was settled for over $350 million.

The risk lies with whether the home health provider was paid for services it did not perform or paid for services with insufficient medical record documentation to support the claim.

For our clients, we conduct billing and coding compliance assessments that focus on the accuracy of the codes submitted, maintaining sufficient medical record documentation to support the claim, and analyzing the strengths and/or weaknesses of the overall compliance program.

As an alternative, home health providers can proactively self-assess their records and internal processes.  Home health providers should conduct annual audits of all providers or locations within the entity. Sample populations should be randomly selected utilizing data or reports generated from the practice management system or billing system. The medical record should be analyzed and tested to confirm that the services billed were properly documented and supported. Finally, the data and results should be tracked and disseminated to the senior leadership team within the organization. Home health providers should maintain a detailed record of these proactive assessments.

Any lessons learned from the proactive assessments will allow home health providers to implement corrective action plans to help mitigate any issues or risks before the government auditors knock at the door, possibly saving money, and hours of extra work and stress.

The views expressed herein are those of the author and do not necessarily reflect the views of Ernst & Young LLP. This material has been prepared for general information only and is not intended to be relied upon as accounting, tax or other professional advice. Please refer to your advisors for specific advice.

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